Signs and Symptoms

January 1, 2002

Signs/SymptomsQuestions

Do You Have The Signs Or Symptoms Below ?

Major Signs and Symptoms of Patients with Chronic Fatigue Syndrome/Fibromyalgia Syndrome

Major Signs and Symptoms of Patients with Gulf War Illness

and …

Physical and laboratory results are not available to diagnose your illness?

Or you may have been diagnosed with a Fatigue Illness, Autoimmune Disease or Infectious Disease of unknown origin,

You may be suffering from a ‘stealth’ pathogenic agent (bacteria, viruses) or other causes.

Often patients are diagnosed with a Somatoforensic or Somatoform disorder, that is they are diagnosed with a disorder that is mainly caused by psychological stress or other mental stressors.

At The Institute for Molecular Medicine and its certified reference diagnostic corporation, International Molecular Diagnostics, Inc., we take pride in providing the latest state-of-the-art technology in analyzing chronic illnesses and providing diagnostic and treatment solutions. In particular, we were among the first to recognize that a majority of patients with chronic illnesses suffer from ‘stealth’ infections that can be identified and successfully treated.

"infections are often misdiagnosed or not even sought - and because of this, infections often are either untreated or are inappropriately treated."

Prof. G. H. Cassell, 37th ICAAC, Toronto, 1997 (JAMA 1997; 278: 2051-2052)

For further Information on:

Gulf War Illness

Fatigue Illnesses Chronic Fatigue SyndromeMyalgic EncephalomyelitisFibromyalgia Syndrome

Autoimmune DiseasesRheumatoid ArthritisInflammatory Bowel Disease(IBD), Amyotrophic Lateral Sclerosis(ALS), Lupus(SLE) Graves' Disease,Multiple Sclerosis (MS), Hashimoto's Disease,Reiter's Disease, Crohn'sDisease, Scleroderma.

Other Chronic Diseases

See appropriate section for additional imformation.

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Date:___________________

CHRONIC FATIGUE/FIBROMYALGIA/ARTHRITIS ILLNESS SURVEY FORM

PROTOCOL: MYCOPLASMAL INFECTIONS IN CHRONIC ILLNESSES

Each Family Member Must Fill Out This Form--Check Those That Apply

NAME:____________________________________ DOB:_____________ RACE: White ____ Black ____ Latino____ Asian____ Other________

ADDRESS:______________________________________________________________________________________ HOME PH:____________________________

IF FAMILY MEMBER: Wife ____ Husband ____ Child ____ Other Relative ___________________________ WORK PH:____________________________

PERSONAL INFORMATION: Male ____ Female ____ Smoker ____ Smokeless Tobacco ____ Date Quit Smoking:_______________ Alcohol _____

EXPOSURE DATA: PREVIOUS LOCATIONS: COMPANY:

__________________________________________________ Dates:__________ to __________ ______________________________________________

RECENT/PRESENT WORK:____________________________________________LOCATION:____________________________________ZIP CODE:__________

DID EITHER PARENT EXPERIENCE ALLERGIES: YES_____ NO_____ Both _____ CHEMICAL SENSITIVITIES: YES_____ NO_____ Both _____

FIRST ONSET OF ILLNESS? Date ____________________ SECOND ONSET? Date _____________________ THIRD ONSET? Date ____________________

INSTRUCTIONS: OF THE FOLLOWING SYMPTOMS, CHECK THOSE THAT APPLY, EVEN IF THEY OCCURRED INTERMITTENTLY. THE FIRST SCALE IS FOR SYMPTOMS BEFORE THE FIRST EPISODE OF ILLNESS. THE SECOND SCALE IS FOR SYMPTOMS AFTER THE FIRST ONSET OF ILLNESS. THE THIRD SCALE IS FOR SYMPTOMS EXPERIENCED AT THE TIME (WITHIN ONE WEEK) WHEN BLOOD WAS DRAWN FOR ANALYSIS. IF YOU FEEL THAT ANY QUESTION IS NOT APPROPRIATE, YOU MAY CROSS IT OUT AND CONTINUE TO FILL OUT THE QUESTIONNAIRE.Heart palpitations

Chest pain

Skipped or extra heartbeats

Racing pulse

Chest pressure (Like a giant rubber band around your chest)

Nasal congestion or stuffiness

Nasal mucus discharge

Sinus pain

Sore throat

Unable to breath deeply

Wheezing, at rest [ ], or with exertion [ ] (Check one or both)

Shortness of breath, at rest [ ], or with exertion [ ]

Coughing frequently

Coughing up thick saliva or phlegm

Frequent clearing of throat

Excessive sneezing

Loss of interest or enthusiasm

Suicidal thoughts

Depression

Nightmares

Unrefreshed Sleep

Irritable

Mood swings

Chronic fatigue, excessive tiredness

Night sweats

Intermittent fever at night

Hair loss

Abnormal change of hair color

Skin rashes

Reddening or flushing of skin

Skin itching

Cracking, peeling of skin

Cuts & wounds slow to heal

White "itchy-scaly" between toes

Unusual skin rashes

Yellowing color (jaundice-like) of skin

Skin sunburn-like sensation

Wart-like growths on skin

Genital itch

Itchy scalp

Difficulty swallowing

Stomach cramps

Stomach pain

Diarrhea (Passage of stools of decreased form, watery)

Gas (Passage of excess gas, flatus)

Bloating

Lack of bladder control (small volume)

More frequent episodes of urination

Episodes of blood in stools

Episodes of blood in urine

Nausea

Vomiting

Regurgitate (throwing up) food

Bleeding gums

Dental abscesses

Increased salivation

Blurred vision

Double or wavy vision

Problems with eyeglasses prescription

Deteriorated night vision

Increased visual sensitivity to light

Black spots (floaters) in eyes

Bothersome eye twitching

Dry eyes

Itchy eyes

Watery eyes

Headaches

Short-term memory loss

Problems thinking and concentrating

Deteriorated penmanship

Lightheadedness

Poor balance or unsteadiness

Dizziness/vertigo

Ringing in ears/tinnitus

Hearing loss

Stuttering or stammering

Difficulty finding words

Numbness of lips

Drooling

Reduced sense of smell

Dry "cotton" mouth

Change in, or lack of taste

Less capacity for alcohol

Swollen glands (neck, armpits, groin)

Toenail or foot fungus

Weak voice or hoarseness

Excessive thirst

Loss of sexual libido (sex drive)

Swollen abdomen

Reduced joint mobility

Joint pain or discomfort

Muscle spasms or cramps

Aching or burning muscles

Numb hands

Tingling hands

Other loss of strength/endurance

Other numbness or tingling (paresthesias)

Trembling, shaking, or twitching

Swelling of ankles

Swelling of body

Black & blue bruising more easily

Aching joints

Pain in lower back

Pain in neck

Excessive hunger

Loss of interest in food

Difficulty sleeping (insomnia)

Difficulty waking up

Sensitivity to cold (easily chilled)

Teeth easily chilled by cold foods

Teeth loose

Frequent infections (specify)

Frequent colds or flu

White coated tongue

Mouth sores

Lip sores

Increase in allergic sensitivities

Bothered by diesel or gasoline exhaust or fumes

Bothered by cigarettes, smoke

(WOMEN) Frequent yeast infections

(WOMEN) Irregular menstrual periods

(WOMEN) Worse PMS

(WOMEN) Worse menstrual cramps

(WOMEN) Cervical pain

(WOMEN) Endometriosis

(MEN) Sexual impotence

(MEN) Aching or swollen testicles

OTHER SIGNS/SYMPTOMS:_____________________________________________

WHAT DO YOU THINK IS THE CAUSE OF YOUR CONDITION?_____________

RANK ORDER OF MOST IMPORTANT SYMPTOMS:

1. _____________________________________________

LABORATORY TESTS:

2. _____________________________________________

Prior to Onset of Illness

¯ At any time After Onset of Illness 3. _____________________________________________

¯ ¯ Not Applicable

¯ ¯ ¯ 4. _____________________________________________

[ ] [ ] [ ] Elevated cholesterol

5. _____________________________________________

[ ] [ ] [ ] High blood pressure

6. _____________________________________________

[ ] [ ] [ ] Low blood pressure

7. _____________________________________________

[ ] [ ] [ ] Large weight loss (______ lbs.)

8. _____________________________________________

[ ] [ ] [ ] Large weight gain (______ lbs.)

[ ] [ ] [ ] __________________________________ 9. ______________________________

[ ] [ ] [ ] __________________________________ 10. _____________________________

[ ] [ ] [ ] __________________________________________________________________

VACCINATIONS / OTHER EXPOSURES:

Prior to Onset of Illness

¯ At any time After Onset of Illness

¯ ¯ Not Applicable

¯ ¯ ¯

[ ] [ ] [ ] Polio Vaccination (Date ________)

[ ] [ ] [ ] DPT Vaccination (Date ________)

[ ] [ ] [ ] Other Vaccination (Date ________)

[ ] [ ] [ ] Other Vaccination (type __________________________________ Date ________)

[ ] [ ] [ ] SMOG or air polution

[ ] [ ] [ ] Gasoline or Diesel fuel/fumes ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Oil fire or smoke ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Pesticide exposure ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Herbiside exposure ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Hair Salon exposure ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] New Office Buildings ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Carpeting or curtains ( within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Organic Chemicals, Glues, Paints ( within 100 meters/yards [ ]; within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Cosmetics, Perfumes, Hair Sprays, Nail Polish ( within 1 meter/yard [ ]; direct contact [ ])

[ ] [ ] [ ] Sewage pools ( within 100 meters [ ]; within 1 meter [ ]; direct contact [ ])

[ ] [ ] [ ] Insects ( within 100 meters [ ]; within 1 meter [ ]; direct contact [ ])

PREVIOUS DIAGNOSES FOR SIGNS AND SYMPTOMS OF PRESENT ILLNESS:

__________________________________________________________________________________

TREATMENTS FOR ANY SYMPTOMS OR ILLNESS BEFORE ONSET OF PRESENT ILLNESS:

__________________________________________________________________________________

TREATMENTS FOR SYMPTOMS OF ILLNESS AFTER ONSET OF PRESENT ILLNESS:

__________________________________________________________________________________

THE ABOVE INFORMATION WILL ONLY BE USED TO COMPARE SIGNS AND SYMPTOMS WITH INFECTIOUS AGENTS FOUND IN BLOOD TESTS. YOUR IDENTITY AND YOUR TEST RESULTS WILL BE KEPT CONFIDENTIAL AND WILL NOT BE RELEASED TO ANY INSURANCE COMPANY, EMPLOYER, LOCAL, STATE OR FEDERAL GOVERNMENT AGENCY IN ANY FORM THAT COULD COMPROMISE PATIENT CONFIDENTIALITY WITHOUT YOUR WRITTEN APPROVAL.

PLEASE DIRECT ANY QUESTIONS TO AND SEND YOUR SURVEY FORM TO THE ADDRESS BELOW:

Garth L. Nicolson, Ph.D.

Chief Scientific Officer and Research Professor

The Institute for Molecular Medicine (a nonprofit research institute)

15162 Triton Lane, Huntington Beach, CA 92649-1041 Phone: (714) 903-2900 Fax: (714) 379-2082 Email: gnicolson@...

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